An Ultrasound-Guided Regional Anesthesia Elective for Emergency Medicine Residents

Audience This ultrasound-guided regional anesthesia elective is designed for emergency medicine residents. Length of Curriculum The proposed length of this curriculum is over one week. Introduction Ultrasound-guided regional anesthesia (UGRA) is a useful tool in the emergency department (ED) for managing painful conditions, and many programs have identified that these are useful skills for emergency providers; however, only about 53% of programs report teaching UGRA as part of their core curriculum, and there currently are no widely available or peer reviewed nerve block curricula designed for emergency medicine residents. Educational Goals To deliver an immersive 1-week elective to provide residents a strong foundation in principles of UGRA and an introduction to 14 nerve block procedures applicable to care provided in the ED. Educational Methods The educational strategies used in this curriculum include: instructional videos, written and online independent learning materials, one-on-one teaching at the bedside with an emergency ultrasound fellow, simulation of nerve block techniques using a femoral nerve block task trainer, and performance of supervised nerve block procedures on patients in the ED. Research Methods All residents provided feedback through an online survey after completing the elective. Results Eight residents completed the elective in the first year of implementation. Following completion of the UGRA curriculum, 8/8 (100%) of residents reported increased level of confidence in performing UGRA. In addition, 8/8 (100%) of residents reported they were “likely” or “very likely” to incorporate UGRA into their future EM practice. All 8 (100%) residents responded they were “very likely” to recommend the elective to other trainees. The elective received high ratings for overall quality with an average rating of 9.4 out of 10 (±0.7). Discussion An elective in ultrasound-guided regional anesthesia can be successfully incorporated into an emergency medicine training program. The curriculum was successful in providing focused training in UGRA and resulted in increased resident confidence in performing nerve block procedures. Topics Ultrasound-guided regional anesthesia, nerve block, resident, elective, pain.


Problem identification, general and targeted needs assessment:
Despite the benefits of UGRA, many EM residents do not receive focused education in performing ultrasound-guided nerve blocks. In a study of residency programs in the United States, nearly all respondents believed that UGRA was a necessary skill for all EM physicians to learn; 5 however, only 53% of residency training programs reported teaching UGRA as part of their core ultrasound curriculum. While a number of textbook and online resources exist, including a web-based tutorial for anesthesia residents 6 and a recent review, 3 there is no UGRA curriculum available to EM residents. Nearly all EM trainees in the United States complete a rotation dedicated to instruction in bedside ultrasound and attain basic ultrasound skills. 7 Studies have shown that EM residents, after acquiring basic ultrasound skills, can perform individual nerve blocks effectively after minimal instruction. 8 An elective specifically designed for EM trainees addresses this gap in training and ensures that future EM physicians are proficient in these important techniques.
The curriculum was designed as a 1-week elective rotation during the PGY2 through PGY4 year, after residents had completed a one-week introductory ultrasound rotation during their PGY1 year. A literature search was performed, open access UGRA resources were reviewed, including the New York School of Regional Anesthesia (NYSORA) website 9 as well as the Highland Emergency Medicine Residency Ultrasound website. 10 We compiled an extensive list of nerve block techniques and selected those most relevant to EM practice. An expert panel of

Objectives:
By the end of this elective learners will be able to:

Goals of the curriculum:
Provide an immersive elective educational experience for EM residents. Residents will focus on the key principles of UGRA and gain experience in 14 nerve blocks commonly performed in the ED.

Objectives of the curriculum:
By the end of this elective learners will be able to: 1. Know the uses and indications for the 14 UGRA techniques described in this elective. 2. Describe the contraindications to performing nerve block procedures. 3. Identify the key anatomic landmarks for each nerve block procedure using ultrasound on models or patients in the ED. 4. Learn maximum allowable doses, duration of action, and uses for commonly used local anesthetic medications. 5. Recognize the signs and symptoms of local anesthetic systemic toxicity (LAST) as well as appropriate management of this condition and indications for Intralipid.

Educational strategies:
The curriculum chart below details our educational strategies, content, learning objectives, intended learners, requirements, and targeted milestones.

Results and tips for successful implementation:
Before the start of the elective, we provided residents with the elective syllabus, a detailed table of all nerve block techniques covered in the course, and a list of print and online resources organized by nerve block technique. The elective educational experience included one-on-one teaching at the bedside with a fellow, simulation of nerve block technique using a femoral nerve block task trainer, and performing fellow-supervised nerve block procedures on patients in the ED. Each resident met with a fellow in the ED for a minimum of three one-on-one sessions, each session scheduled for 2 hours.
Between December 2018 and June 2019, 8 total residents completed the elective. Three PGY2 residents, 2 PGY3 residents and 3 PGY4 residents completed the elective. All residents provided feedback through an online survey after completing the elective. Data collection was given exempt status by our Institutional Review Board. The residents had minimal previous experience with UGRA. 7/8 (87.5%) residents had performed or directly observed 5 or fewer nerve block procedures before the elective. Following completion of the UGRA elective, 8/8 (100%) residents reported increased level of confidence in performing UGRA. 8/8 (100%) residents also reported they were "likely" or "very likely" to incorporate UGRA into their future EM practice. All residents responded they were "very likely" to recommend the elective to other trainees. The elective received high ratings for overall quality with an average rating of 9.4 out of 10 (±0.7).
In free text responses, all residents cited a strength of the elective was one-on-one experience performing UGRA with the fellow. Four residents responded that more opportunities to perform ultrasound-guided nerve blocks on patients would improve the elective.

Associated content:
There are recorded video lectures for each nerve block procedure covered in the elective.

Evaluation and feedback:
Following initial implementation of the curriculum, we received feedback that residents desired more hands-on practice in performing nerve block procedures. We addressed this need by incorporating a femoral nerve block task trainer 11 to simulate a nerve block procedure from start to finish. We also moved oneon-one scanning sessions in the ED from the morning to the afternoon and early evening when more opportunities to perform nerve block procedures on patients were available.
We also received feedback that the provided list of online resources could be supplemented with additional content for each nerve block procedure. In response, we recorded an introductory lecture, 5 to 15 minutes in duration, for each procedure and provided these to residents before their scheduled rotation. Residents reported in their evaluation surveys that these were a useful addition to the curriculum. Appendix A: Ultrasound Guided Regional Anesthesia Elective

Description:
This is a one-week elective providing instruction on ultrasound-guided nerve blocks useful to the emergency physician. Residents will complete a curriculum that includes independent study and hands-on learning of nerve block techniques. Ultrasound fellows and faculty will teach the elective.

Objectives:
1. Learn the uses and indications for common ED blocks as well as the contraindications to performing these procedures. 2. Identify relevant anatomy using ultrasound for common ED nerve blocks. 3. Develop and improve skill/technique for ultrasound guided needle placement. 4. Learn maximum doses, duration of action, indications, and contraindications for commonly used local anesthetics, signs/symptoms of local anesthetic systemic toxicity (LAST), and appropriate treatment and indications for Intralipid.
List of selected nerve blocks to learn during elective: